Working in a tertiary care centre in a developing country, we receive patients from all over the province and country, for acute and chronic care.
At times, initial discussion starts by receiving a patient brief on WhatsApp either provided by the patient or their physician.
Subsequent to clinic visits, it is common practice for a front-line physician to give their business or even personal phone numbers to patients travelling from other cities, or at times within the city, to receive/discuss results of laboratory or radiological investigations, alter medications, or seek guidance at all hours. This is acceptable practice in our institute and in many leading health care institutes all over the world.
WhatsApp and other social media applications have certainly improved patient-physician communication and have markedly improved patient care as a result.
Just like in-person communication, virtual communication is always bilateral. It is difficult to regulate what transpires in both these forms of communication and to ensure that it always stays within professional, predefined boundaries.
Transgression of boundaries can occur from both parties but physicians are supposed to be trained in the art of always keeping all encounters within limits.
It is easier said than done, however, as there are many instances that are not so straightforward and can rather create a quandary for the physicians.
For example, should a physician respond to Eid Mubarak greetings of a patient? Should they respond to a compliment on their photograph displayed on social media?
Should they reject a friend request from a patient whom they helped bring to this world, and have been treating for 20 years? Can they even make a social media profile where they express their political opinions?
Professional boundaries in medical practice are not well-defined. In general, they are the parameters that describe the limits of a fiduciary relationship in which one person, the patient, entrusts another, a physician, for their well-being.
Physicians are in a position of power in this skewed relationship where they have informational, social, emotional, geographical, and physical power over their patients who are inherently vulnerable due to their dependence upon them.
But when we talk about physician-patient boundaries, we find them non-existent or at best poorly defined in a country like Pakistan where ethics education is conspicuous by its absence and is synonymous with morality.
Physicians are generally held in reverence and called ‘doctor chucha’ and ‘doctor aunty’ rather than by their names and often hear sentences like “You are like my father, please decide as you know best.”
Family physicians treating patients for years are themselves treated like family members, are invited to family functions, and receive mithai on religious festivals.
Pakistan is a country where dual relationships with bilateral advantages is a norm rather than exception. In our culture, ethics of care prevail more than individualistic ethics, and health care decision making takes place in consultation with distant relatives and varied neighbours.
Where giving gifts is a sign of respect and thanks, where physicians waive health care fee of deserving patients occasionally and feel obligated to receive home-made sweets as a sign of gratitude, where patients feel let down if the entire clan does not come to visit when they are sick, promoting individualistic ethics is difficult.
Despite these Pakistani peculiarities, it still doesn’t mean that there is no place for ethics whereby physicians maintain a professional distance from their patients. Ethics is what ought to be no matter what.
It is a standard of behaviour towards others and self within societies, and clinical ethics are the standards of behaviour towards patients, colleagues, and society during the course of providing clinical care.
It cannot be emphasised enough that protection of patient vulnerability under all circumstances must be the central premise on which these standards are formulated.
However, there is no code of professional conduct or regulative guideline in the world that defines standards of behaviour clearly under all possible circumstances – and there cannot be.
Most guidelines are just guidelines; they provide general principles of behaviour and leave it to the contextual application for the physicians. Physicians in Pakistan are either not trained in bioethics, or consider it superfluous while practicing medicine.
Ethical behaviour develops only with repeated practice. Even in institutes where ethics is being taught in theory, poor role modelling bars the translation of theory into practice.
Systems of accountability are either non-existent or applied discriminately, penalising the lowest in the hierarchy while treating higher-ups with leniency.
Law, which is minimal ethics, becomes the last resort to provide answers to questions that ought to be deliberated within the physicians’ fraternity as issues of a most significant nature.
Pakistan needs to move towards addressing these issues, and when it does so, the deliberations should involve all the concerned parties. The focus should be on contextually acceptable norms, so as to be acceptable to the local healthcare community.
We need empirical research in clinical ethics to develop relevant curricula, train teachers to educate current and future health care workers, provide good role modelling to help translate theoretical knowledge into practice, and robust systems of internal and external accountability.
That does not mean that unethical behaviour or unprofessional acts will never occur, but that they will not be due to ignorance or lack of knowledge.
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